April 8, 2021 Agenda 9:30 A.M

Virtual Pre-hospital Services Committee April 8, 2021 Agenda 9:30 a.m.

I. Introductions II. Approve Agenda III. Minutes IV. Medical Issues A. Coronavirus Update Dr. Shepherd/Steve Carroll V. New Business A. 334 – Prehospital Personnel Mandatory Training Requirements Andrew Casey B. New Policy - Prehospital Capnography Dr. Shepherd/ Andrew Casey C. 504 - BLS and ALS Unit Equipment and Supplies Andrew Casey VI. Old Business A. PSC - Chairman Nominations VII. Informational/Discussion Topics A. Intraosseous Devices VIII. Policies for Review A. 335 - Out of County Paramedic Internship Approval Process B. 342 - Notification of Personnel Changes-Provider C. 601 – Medical Control at the Scene: EMS Prehospital Personnel D. 629 – Hospice Patient Care E. 705.16 – Neonatal Resuscitation IX. Agency Reports A. Fire Departments B. Ambulance Providers C. Base Hospitals D. Receiving Hospitals E. Law Enforcement F. ALS Education Program G. EMS Agency H. Other X. Closing

VCFD V/College SVH -ER SVH -ER SJRMC -ER SJRMC -ER -ER SJPVH -ER SJPVH OFD OFD LRRMC ER - LRRMC ER - Lifeline Lifeline GCA GCA FFD FFD PD CSUCI PD CSUCI OVCH -ER OVCH -ER VCMC -ER VCMC -ER CMH ER - CMH ER - AMR AMR VNC - Dispatch - VNC VNC VNC VCFD For Attendance, please initial your name for the current month your current forthe initial name Attendance,For please Prehospital Services Committee 2021

Agency Tapking O'Connor Shorts Tilles McShea Larsen Sikes Hutchison Villa Strong Moore Brooks Williams Rosolek Sanders TBD Panke Herrera Deboni Drehsen Ferguson Pulido Gallegos Gillett Querol Levin Riggs Goguen Ellis Gregson Schwab Williams

LastName Aaron Tom Kristen Ira Kathy Todd Chris Stacy Jaime Adam Bethany Kyle Joey James Mike Chad Bill Curtis Charles Catherine Ed Tom John Amy Ross Cassie Daniel Heather Erica David Joseph

FirstName

1/7/2021 JW KM BM MS CD TO TG HE KB AT JG RL TL JV IT 2/11/2021 JW KM BM DG AQ EG TO CS TG HE KS AS CF EP AT JG RL TL JV IT 3/11/2020

4/8/2021

5/13/2021

6/10/2021

7/8/2021

8/12/2021

9/9/2021

10/14/2021

11/11/2021

12/9/2021 % VCMC VCMC VFF VFF VCSO SAR VCSO SAR VNC CMH Hospital Assoc. Parks State AMR/GCA LMT LMT EMS EMS EMS EMS EMS EMS EMS EMS EMS VCSO SAR VCMC-SPH EMS EMS eo ae a names Below

Agency Duncan Hill Vilaseca Lane Tolle Hadland Chase Hall Strickland Futoran Gonzales Frank Winter Casey Garcia Gil-Stefansen Beatty Hansen Salvucci Shepherd Perez Carroll Conahey Vicencio Rosa Frey Date Change/cancelled - not counted against member for attendance for member against counted not - Change/cancelled Date

LastName Thomas Jessica James Mike Jonathon Don David Elaina Audra Jack Nicole Steve Jeff Andrew Martha Adriane Karen Erik Angelo Daniel Randy Steve Dave Angela Chris Julie

FirstName

1/7/2021 MG JW DC DC DS RP SC TD AC CR AS JV JF JF 2/11/2021 MG JW DC DC DS RP SC TD AC CR KB AS AS JV 3/11/2020

4/8/2021

5/13/2021

6/10/2021

7/8/2021

8/12/2021

9/9/2021

10/14/2021

11/11/2021

12/9/2021 % Virtual Pre-hospital Services Committee March 11, 2021 Minutes 9:30 a.m.

Topic Discussion Action Approval II. Approve Agenda 705.27 was not on the agenda as Approved Motion: Kathy McShea stated last meeting by Andrew Casey. Seconded: Tom O’Connor This policy will be presented at the next Passed unanimous meeting. III. Minutes Change - VCMC will be a back up to Approved Motion: Kathy McShea St. Johns Oxnard construction project. Seconded: Tom O’Connor Passed unanimous IV. Medical Issues Coronavirus Update COVID numbers still dropping and we anticipate being in the red tier next week Vaccinating the education sector System wide ED diversion We are adjusting policies as needed for COVID issues Mask mandate will be adjusted in the near future for vaccinated personnel

V. New Business A. 310 – Paramedic Scope of The committee felt there should be a Approved Motion: Kathy McShea Practice new policy for paramedic students. Seconded: Jaime Villa Passed unanimous B. 705.07 Dr. Chase discussed the treatment for Tabled until next meeting for further cardiac arrest due to exsanguination review. Dr. Shepherd and Andrew Casey will work on this policy. C. 705.08 Dr. Chase discussed the treatment for Tabled until next meeting for further cardiac arrest due to exsanguination review. Dr. Shepherd and Andrew Casey will work on this policy. D. 705.12 Approved Motion: Ira Tilles Seconded: John Gillett Passed unanimous E. 705.14 - Approved Motion: Ira Tilles Seconded: John Gillett Passed unanimous F. 727 - Need to change heart rate from 45 to 40 to match 705. (brady policy) G. 1105 – Mobile MICN Approved Motion: Kathy McShea Developmental Course and Seconded: Tom O’Connor Examination Procedure Passed unanimous VI. Old Business

A. PSC Chairman Nominations The 4 people chosen to be on the Bring back recommendation to PSC in nominating committee are: Dr. Tilles, April. Heather Ellis, Jeff Winter and Bethany Moore. VII. Informational A. 1404- These policies were presented to PSC. Approved at TORC Minor formatting issues B. 1405 - These policies were presented to PSC. Approved at TORC List of anti-coagulants and anti- platelets will be placed on VCEMS website by EMS.

VIII. Policies for review 303 - Approved Motion: Chris Sikes Seconded: Tom O’Connor Passed unanimous 507 - Tabled – Will meet with providers and bring back. 705.13 - Approved with changes Motion: Kathy McShea Seconded: Tom O’Connor Passed unanimous 717 - Will bring back Motion: Chris Sikes Seconded: Charles Drehsen Passed unanimous X. Agency Reports A. Fire departments VCFPD – none VCFD- none OFD – none Fed. Fire – none SPFD – none FFD – none B. Transport Providers LMT – none AMR/GCA – none AIR RESCUE – none C. Base Hospitals SAH – none LRRMC – none SJRMC – Construction is 1 month from completion. No change to ambulances. The day our base station is moved, VCMC will act as base. VCMC – none D. Receiving Hospitals PVH – none SPH – none CMH –. none OVCH – none E. Law Enforcement VCSO –none CSUCI PD – none F. ALS Education Ventura College – Students are at clinical sites and will be in the field in March. Programs G. EMS Agency Steve – none Dr. Shepherd – none Chris – none Katy –none Karen – none Julie –none Randy – none H. Other XI. Closing Meeting adjourned at 11:30

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number: Pre-Hospital Personnel Mandatory Training Requirements 334

APPROVED: Date: DRAFTJune 1, Administration: Steven L. Carroll, EMT-P 2014

APPROVED: Date: DRAFTJune 1, Medical Director Angelo Salvucci, MD 2014 Origination Date: September 14, 2000 Date Revised: May 8, 2014 Effective Date: DRAFT June 1, 2014 Date Last Reviewed: May 8, 2014 Review Date: May 31, 2017

I. PURPOSE: To define the requirements for mandatory training sessions for EMTs, Paramedics, EMT-ALS Assist SAR EMTs, MICNs and Flight Nurses in Ventura County. II. AUTHORITY: Title 22, California Code of Regulation, Division 9, Section 100175 and Chapter 6. Health and Safety Code Section 1797.214, 1797.220 and 1798.200. III. POLICY: All pre-hospital personnel have requirements for on-going authorization or accreditation to provide pre-hospital care in Ventura County. These requirements are outlined in VCEMS Policy 318 for Paramedics, 306 and 803 for EMTs, 1201 for Flight Nurses and SAR EMTs and 322 for MICNs. III. PROCEDURE: A. EMS Updates – Applies to all personnel listed above except EMTs. Personnel shall attend mandatory education and/or testing on updates to local policies and procedures (EMS Update), which will be presented by the Base Hospitals in May and November each year (minimum of 12 opportunities to attend each session). Prehospital Services Committee members who attend 75% of the scheduled meetings over the previous 6 months may have this requirement waived. B. MCI Training – Applies to all personnel listed above. Personnel shall attend initial Basic or Advanced MCI training within 6 months of initially starting the certification or accreditation process and complete bi-annual refreshers as indicated in VC EMS Policy 131..

Formatted: Indent: Left: 0" C. Resuscitation Training – Applies to Paramedics, MICN’s, and Flight Nurses only. 1. Adult Resuscitation– Paramedic, MICN, and Flight Nurse providers must obtain AHA ACLS certification or American Red Cross ALS certification within three months of initially starting the certification or accreditation process. Adult resuscitation certification must be maintained as current while practicing in Ventura County. Policy 334: Prehospital Personnel Mandatory Training Requirements Page 2 of 5

2. Pediatric – All personnel listed above with the exception of MICN’s, shall obtain a Handtevy Pediatric Provider course completion certification within 3 months of initially starting the accreditation process. Course completion must be maintained as current while practicing in Ventura County. MICN’s who have received Handtevy Orientation training may utilize AHA or American Red Cross Pediatric Advanced Life Support (PALS), Pediatric Education for Prehospital Providers (PEPP), or Emergency Nurse Pediatric Course (ENPC), to meet the pediatric resuscitation training requirement. In all cases certification must be maintained as current while practicing in Ventura County.

C. Grief Training – Applies to all personnel listed above except MICNs. Formatted: Indent: Left: 0", First line: 0"

All personnel shall be provided the self-study packet titled “Dealing with Grief: A Workbook for Formatted: Heading 1, Indent: Left: 0" Prehospital Personnel.” After finishing the self-study packet, personnel shall complete the post-test and evaluation and mail them to VC EMS for a course completion and 2 hours CE credit. This requirement shall be completed within 6 months of initially starting the certification or accreditation process.

D. Emergency Response to Terrorism – Applies to all personnel listed above. Formatted: Indent: Left: 0", First line: 0"

All personnel shall be provided the self-study packet titled “Emergency Response to Formatted: Indent: Left: 0.5" Terrorism.” After finishing the self-study packet, personnel shall complete the post-test and mail it to VC EMS for a course completion and 3 hours CE credit. This requirement shall be completed within 6 months of initially starting the certification or accreditation process. DE. Paramedic Skills Refresher – Applies to Paramedics only 1. Paramedics shall attend one skills refresher session during the first year of licensure and one skills refresher in the second year of licensure. 2. Skills Refreshers will be offered at least 4 times in March and 4 times in September and will be offered over a 3 week period. Dates, times, and locations for the Skills Refreshers will be published one year in advance. Late arrivals will not be admitted into the Skills Refresher. F. Nerve Agent Training – Applies to Paramedics only

All personnel shall be provided the self study PowerPoint presentation entitled “Ventura County Formatted: Indent: Left: 0.5" EMS Nerve Agents: Recognition and Treatment”. Providers shall forward a copy of the attendance roster to VCEMS to verify completion of the training. New employees shall complete training within 6 months of initially starting the accreditation process. G. Field Intubation Refresher Training– Applies to Paramedic and SAR Flight Nurses only

One intubation refresher session per six (6) month period based on license cycle as described Formatted: Indent: Hanging: 0.5" in Policy 318. Policy 334: Prehospital Personnel Mandatory Training Requirements Page 3 of 5

H. Advanced Cardiac Life Support (ACLS) - Applies to all personnel listed above except EMTs and SAR-EMTs. ACLS course completion certificate shall be obtained within three months of initially starting the certification or accreditation process and remain current.

I. Pediatric Advanced Life Support (PALS) or Pediatric Education for Prehospital Providers Formatted: Indent: Left: 0", First line: 0" (PEPP) - Applies to Paramedics and MICNs. PALS or PEPP course completion certificate shall be obtained within six months of initially starting the accreditation process and remain current. Emergency Nurse Pediatic Course (ENPC) is also an acceptable pediatric course for the purposes of MICN authorization / reauthorization. EJ. Failure to complete mandatory requirements: 1. Level II Paramedics who fail to complete any of these requirements will immediately revert to a Level I Paramedic according to VCEMS Policy 318. The Paramedic’s accreditation to practice in Ventura County will be suspended after the State required 15 day notice until the following remediation criteria has been met. All other required personnel who fail to complete these requirements will have their authorization immediately suspended. 2. Reinstatement of authorization or accreditation: a. Personnel who have not completed or maintained MCI Training, adult resuscitation, or pediatric resuscitation training requirements as outlined above Grief Training or Emergency Response to Terrorism must complete the requirementss and provide documentation of completion to VC EMS for determination on reinstatement. b. Personnel not attending EMS Update must complete the following remediation criteria. 1) Personnel will attend a make-up session to be scheduled by VC EMS within 2 weeks of the last regularly scheduled EMS Update session. 2) Personnel will submit a written statement to VC EMS explaining the circumstances why this requirement could not be met. 3) Submit a $125.00 fine. 4) A written post-test will be administered, and must be successfully completed by achieving a minimum passing score of 85%. 5) If the VC EMS make up session is not attended, the employer may elect to assist the person in completing the requirement. a) The employer shall use the materials and test supplied by VC EMS. Policy 334: Prehospital Personnel Mandatory Training Requirements Page 4 of 5

b) The employer will be responsible to forward the written statement and $125.00 fine to VC EMS. c) The employer will administer the written test and will forward it to VC EMS for scoring. Minimum passing score will be 85%. d) A make up session arranged by an employer will be approved by VC EMS before it is presented. c. Paramedics not attending Skills Refresher must complete the following remediation criteria. 1). Paramedic will submit a written statement to VC EMS explaining the circumstances why this requirement could not be met. 2) Submit a $125.00 fine. 3) Paramedic will attend a remediation session on documentation and review of VC EMS Policy 318 to be administered by VC EMS. 4) ALS provider will confirm paramedic has read and reviewed VC EMS Policy and Procedure Sections 6 & 7. 5) ALS provider will be responsible to coordinate a Skills Refresher make-up session conducted by either an ALS Service Provider Medical Director, base hospital physician or their designee. Skills Refresher make-up will include all skills covered at the most recent Skills Refresher. 6) ALS provider will submit a written plan of action to VC EMS to include: course curriculum, date and location of Skills Refresher make-up, equipment to be used and names of instructors. 7) Completed reinstatement checklist, will be submitted to VC EMS for review and determination on reinstatement of paramedic accreditation. Policy 334: Prehospital Personnel Mandatory Training Requirements Page 5 of 5

PARAMEDIC SKILLS REFRESHER REINSTATEMENT CHECKLIST

Paramedic Name: ______CA License No.: ______

Action Date Signature 1. Read and reviewed EMS Policy and Procedure Sections 6 & 7 (signed by provider). 2. Orientation at EMS Office, Policy 318 review. 3. Documentation Station: Administered by EMS 4. Skills refresher verification: The skills must be signed off by a BH physician or Medical Director associated with your employer. a. b. c. d. e. f. g.

After the above is completed, please forward the checklist to the EMS Agency for review and determination on reinstatement of paramedic accreditation.

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Prehospital Capnography Policy Number

APPROVED: Date: Administration: Steve L. Carroll, Paramedic APPROVED: Date: Medical Director: Daniel Shepherd, M.D. Origination Date: Date Revised: Effective Date: Date Last Reviewed: Review Date:

I. PURPOSE: To outline the use of capnography in the assessment and treatment of EMS patients.

II. AUTHORITY: California Health and Safety Code, §1798, §1798.2; §1798.160 and §1798.170 and California Code of Regulations, Title 22, §100145 and §100146.

III. PRINCIPLES:

1. Ventilation is an active process, which is assessed with end-tidal CO2 measurement. End-tidal CO2 measurement is an indication of air movement in and out of the lungs. The “normal” value of exhaled CO2 is 35-45 mmHg.

2. Oxygenation is a passive process, which occurs by diffusion of oxygen across the alveolar membrane into the blood. The amount of oxygen available in the bloodstream is assessed with pulse oximetry.

3. Capnography provides both a specific value for the end-tidal CO2 measurement and a continuous waveform representing the amount of CO2 in the exhaled air. A normal capnography waveform is square, with a slight upslope to the plateau phase during exhalation. (See figures below) The height of the waveform at its peak corresponds to the ETCO2.

4. Capnography is necessary to monitor ventilation. For patients requiring positive pressure ventilation, capnography is most accurate with proper mask seal (two-hand mask hold for adults during bag-mask ventilation) or with an advanced airway.

5. Capnography can also be applied via a nasal cannula device to measure end-tidal CO2 in the spontaneously breathing patient. It is useful to monitor for hypoventilation, in patients who are Policy XXX: [INSERT POLICY TITLE HERE] Page 2 of 8

sedated either due to ingestion of substances or treatment with medication with sedative properties such as midazolam or opioids.

6. Capnography is standard of care for confirmation of advanced airway placement. Unlike simple colorimetric devices, capnography is also useful to monitor the airway position over time, for ventilation management, and for early detection of return of spontaneous circulation (ROSC) in patients in cardiac arrest. 7. Capnography is the most reliable way to immediately confirm advanced airway placement. Capnography provides an instantaneous measurement of the amount of CO2 in the exhaled air. The absence of a waveform, and/or values < 10 mmHg, suggest advanced airway misplacement. However, patients in cardiac arrest or profound shock may also have end-tidal CO2 values <10 despite proper airway placement.

8. Capnography provides the most reliable way to continuously monitor advanced airway position. The waveform provides a continuous assessment of ventilation over time. A normal waveform which becomes suddenly absent suggests dislodgement of the airway and requires clinical confirmation.

9. The value of exhaled CO2 is affected by ventilation (effectiveness of CO2 elimination), perfusion (transportation of CO2 in the body) and metabolism (production of CO2 via cellular metabolism). In addition to the end-tidal CO2 value, the ventilation rate as well as the size and shape of the capnograph must be used to interpret the results.

10. Decreased perfusion will reduce the blood flow to the tissues, decreasing offload of CO2 from the lungs. Therefore, patients in shock and patients in cardiac arrest will generally have reduced end-tidal CO2 values.

11. A sudden increase in perfusion will cause a sudden rise in end-tidal CO2 values and is a reliable indicator of ROSC. It is common to have an elevated ETCO2 reading after ROSC. Hyperventilation should not be done to in attempt to normalize the ETCO2.

12. Ventilation can have varied effect on CO2 measurement. Generally, hyperventilation will reduce end-tidal CO2 by increasing offload from the lungs. Hypoventilation and disorders of ventilation that reduce CO2 elimination (e.g., COPD), will cause CO2 to build up in the body.

13. End-tidal CO2 can be detected using a colorimetric device (ETCO2 detector). These devices provide limited information about ETCO2 as compared to capnography. Colorimetric devices do not provide continuous measurement of the value of CO2 in the exhaled air and cannot be used in ongoing monitoring. Colorimetric devices should only be used for confirmation of endotracheal tube placement if capnography is unavailable due to equipment failure.

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 3 of 8

IV. POLICY: 1. Capnography monitoring is indicated and shall be used for patients meeting any of the following indications; a. Patients receiving positive pressure ventilation via CPAP or BVM. b. Patients at risk of developing respiratory failure, hypoventilation, or apnea due to overdose, recreational use of, or EMS administration of medications or substances with sedative properties such as alcohol, benzodiazepines, or opiates. c. Patients in cardiac arrest. d. Patients who in the paramedic’s judgement are at risk for developing respiratory failure, hypoventilation, or apnea.

2. Capnography may also be utilized when the paramedic determines it may aid the clinical assessment.

3. Providers will initiate capnography monitoring as soon as feasible and ensure that the capnography waveform is visible on screen throughout patient care or until no longer indicated.

4. Once initiated, ALS providers will continuously evaluate the capnography waveform and intervene accordingly..

5. Once capnography monitoring is in place providers will ensure that the waveform remains visible on the monitor screen continuously throughout the duration of care or until no longer indicated.

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 4 of 8

V. PROCEDURE: 1. Chose the appropriate CO2 measuring device; a. Nasal cannula device for spontaneously breathing patients with or without CPAP b. Sidestream or mainstream inline measuring device for patients receiving BVM ventilations via BLS or ALS airway adjunct.

2. Attach measuring device to the monitor, wait for device to initialize, then attach to patient.

3. Assess that a capnography waveform is present with each breath prior to considering measurements to be accurate.

4. Assess EtCO2 value.

5. Assess for abnormalities in capnography waveform or EtCO2 value initially and for trends over time.

6. Endotracheal tube confirmation: per policy 710

VI. WAVEFORM INTERPRETATION

1. Normal shape of the capnograph depicted below

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 5 of 8

2. Esophageal Intubation (Low values and irregular waveform or flat line).

3. Obstructed or dislodged endotracheal tube (sudden loss of normal waveform followed by low irregular waveform or flat line).

4. Hyperventilation (Normal waveform with reduced height, < 35 mmHg, and high ventilation rate)

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 6 of 8

5. Hypoventilation/ Bradypnea (Normal waveform with increased height, > 45 mmHg)

6. Hypoventilation/ Low tidal volumes (Normal waveform with reduced height, < 35 mmHg, and slow ventilation rate; A similar reduced height waveform can also be seen with shock - see progressive hypotension below).

7. Air Trapping / Breath Stacking (Box wave forms that show increasing values with each successive breath)

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 7 of 8

8. Bronchospasm (“Shark Fin Pattern”)

9. Return of Spontaneous Circulation (Sudden increase in values in a patient in cardiac arrest)

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

Policy XXX: [INSERT POLICY TITLE HERE] Page 8 of 8

10. Progressive Hypotension or Re-arrest (Progressive decrease in values with each successive breath)

S:\ADMIN\EMS Admin\Committees\PSC\2021\April\Capnography_DRAFT_1.docx

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number: BLS And ALS Unit Equipment And Supplies 504

APPROVED: Administration: Steven L. Carroll, Paramedic Date: December 1, 2020

APPROVED: Medical Director Daniel Shepherd, MD Date: December 1, 2020 Origination Date: May 24, 1987 Date Revised: October 15, 2020 Effective Date: December 1, 2020 Last Reviewed: October 15, 2020 Review Date: October 31, 2021

I. PURPOSE: To provide a standardized list of equipment and supplies for response and/or transport units in Ventura County. II. POLICY: Each response and/or transport unit in Ventura County shall be equipped and supplied according to the requirements of this policy. III. AUTHORITY: California Health and Safety Code Section 1797.178, 1797.204, 1797.218, 1797.221 and California Code of Regulations Sections 100148, 100306, 100404 IV. PROCEDURE: The following equipment and supplies shall be maintained on each response and/or transport unit in Ventura County.

Deviation from the standards outlined in this policy shall only be authorized with written approval (see attached Equipment/Medication Waiver Request form) from the VCEMS Medical Director. Mitigation attempts should be documented in the comment section on the waiver request form, such as what vendors were contacted, etc. Policy 504: ALS and BLS Unit Equipment and Supplies Page 2 of 5

Search and PSV/CCT FR/ALS ALS / BLS Unit Rescue Minimum Minimum Minimum Amount Minimum Amount Amount Amounts A. ALL BLS AND ALS RESPONSE AND/OR TRANSPORT UNITS Clear masks in the following sizes:

Adult 1 adult Child 1 each 1 each 1 each

Infant 1 infant Neonate Bag valve units Adult (1,000 mL) 1 each 1 each 1 each 1 adult Child (500 mL) Infant (240 mL) Nasal cannula 3 3 3 3 Adult Nasopharyngeal airway 1 each 1 each 1 each 1 each (adult and child or equivalent) Continuous positive airway pressure (CPAP) device 1 per size 1 per size 1 per size 1 per size Nerve Agent Antidote Kit 9 9 9 0 Blood glucose determination devices (optional for non-911 BLS units) 2 1 1 1 Oral glucose 15gm unit dose 1 1 1 1 Oropharyngeal Airways Adult Child 1 each size 1 each size 1 each size 1 each size Infant Newborn 10 L/min for 10 L/min for 20 10 L/min for Oxygen with appropriate adjuncts (portability required) 10 L/min for 20 minutes 20 mins. mins. 20 mins. Portable suction equipment 1 1 1 1 Transparent oxygen masks Adult nonrebreather 3 2 2 2 Child 3 2 2 2 Infant 2 2 2 2 Bandage scissors 1 1 1 1

Bandages

• 4"x4" sterile compresses or equivalent 12 12 12 5 • 2",3",4" or 6" roller bandages 6 2 6 4 • 10"x 30" or larger dressing 0 2 2

Blood pressure cuffs 1 Thigh 1 1 1 1 Adult 1 1 1 1 Child 1 1 1 1 Infant 1 1 1

Emesis basin/bag 1 1 1 1 Flashlight 1 1 1 1 Traction splint or equivalent device 1 1 1 1 Pneumatic or rigid splints (capable of splinting all extremities) 4 4 4 4 Potable water or saline solution 4 liters 4 liters 4 liters 4 liters Cervical spine immobilization device 2 2 2 2 Spinal immobilization devices

Policy 504: ALS and BLS Unit Equipment and Supplies Page 3 of 5

Search and PSV/CCT FR/ALS ALS / BLS Unit Rescue Minimum Minimum Minimum Amount Minimum Amount Amount Amounts KED or equivalent 1 1 1 1 60" minimum with at least 3 sets of straps 1 0 1 Sterile obstetrical kit 1 1 1 1 Tongue depressor 4 4 4 4 Cold packs 4 4 4 4 Tourniquet 1 1 1 1 1 mL,5 mL, and 10 mL syringes with IM needles 4 4 4 4 Automated External Defibrillator (if not equipped with ALS monitor/defibrillator) 1 1 1 1 Personal Protective Equipment per State Guideline #216 Rescue helmet 2 1 0 0 EMS jacket 2 1 0 0 Work goggles 2 1 0 0 Tyvek suit 2 L / 2 XXL 1 L / 1 XXL 0 0 Tychem hooded suit 2 L / 2 XXL 1 L / 1 XXL 0 0 Nitrile gloves 1 Med / 1 XL 1 Med / 1 XL 0 0 Disposable footwear covers 1 Box 1 Box 0 0 Leather work gloves 3 L Sets 1 L Set 0 0 Field operations guide 1 1 0 0 OPTIONAL EQUIPMENT Occlusive dressing or chest seal Hemostatic gauze per EMSA guidelines B. TRANSPORT UNIT REQUIREMENTS Ambulance cot and collapsible stretcher; or two stretchers, one of which is collapsible. 1 0 0 1 Straps to secure the patient to the stretcher or ambulance cot, and means of securing the stretcher or ambulance cot in 1 Set 0 0 1 Set the vehicle. Soft Ankle and wrist restraints. 1 0 0 0 Sheets, pillow cases, blankets and towels for each stretcher or ambulance cot, and two pillows for each ambulance 1 0 0 0 Bedpan 1 0 0 0 Urinal 1 0 0 0

Policy 504: ALS and BLS Unit Equipment and Supplies Page 4 of 5

Search and PSV/CCT FR/ALS ALS / BLS Unit Rescue Minimum Minimum Minimum Amount Minimum Amount Amount Amounts C. ALS UNIT REQUIREMENTS Cellular telephone 1 1 1 1

Supraglottic Airway Devices: I-Gel with passive oxygenation port 2 of each 1 of each 1 of each 1 of each Sizes 1, 1.5, 2, 2.5, 3, 4, 5 I-Gel Airway Support Straps 2 2 2 2 Arm Boards 9” 3 0 1 0 18” 3 0 1 0 Cardiac and waveform capnography monitoring equipment 1 1 1 1 CO2 monitor Infant (<0.5 mL sidestream or <1 mL mainstream adaptor) 2 of each 2 of each 2 of each 2 of each Pediatric / Adult ( 6.6 mL sidestream or < 5 mL mainstream adaptor)

Formatted: Indent: Left: 0" CO2 Monitor Adult size EtCO2 sampling nasal cannula 1 of each 1 of each 1 of each 1 of each Pediatric size EtCO2 sampling nasal cannula Formatted: Subscript Colorimetric CO2 Detector Device 1 1 1 1 1 adult – No Defibrillator pads or gel 3 3 3 Peds. Defibrillator w/adult and pediatric paddles/pads 1 1 1 1 EKG Electrodes 10 sets 3 sets 3 sets 6 sets 4, 5, 6, 6.5, Endotracheal intubation tubes, sizes 6.0, 6.5, 7.0, 7.5, 8.0 with stylets 1 of each size 1 of each size 1 of each size 7, 7.5, 8 EZ-IO intraosseous infusion system 1 Each Size 1 Each Size 1 Each Size 1 Each Size Intravenous Fluids (in flexible containers) • Normal saline solution, 100 ml 2 1 1 1 • Normal saline solution, 500 ml 2 1 1 1 • Normal saline solution, 1000 ml 6 2 4 3 IV admin set - macrodrip 4 1 4 3 6 each 14, 16, 18, 20 2 each 2 each IV catheter, Sizes l4, l6, l8, 20, 22, 24 3 each 22 2 each

3 each 24 Laryngoscope, replacement bulbs and batteries 1 set 1 set 1 set 1 set

Curved blade #2, 3, 4 1 each 1 each 1 each 1 each Straight blade #1, 2, 3 1 each 1 each 1 each 1 each Magill forceps 1 1 1 1 Adult 1 1 1 1 Pediatric Intranasal mucosal atomization device 2 2 2 2 Nebulizer 2 2 2 2 Nebulizer with in-line adapter 1 1 1 1 Needle Thoracostomy kit 2 2 2 2 Pediatric length and weight tape 1 1 1 1 SpO2 Monitor (If not attached to cardiac monitor) 1 1 1 1 SpO2 Adhesive Sensor (Adult, Pediatric, Infant) 1 of each 1 of each 1 of each 1 of each

Policy 504: ALS and BLS Unit Equipment and Supplies Page 5 of 5

Search and PSV/CCT FR/ALS ALS / BLS Unit Rescue Minimum Minimum Minimum Amount Minimum Amount Amount Amounts OPTIONAL ALS EQUIPMENT (No minimums apply) Flexible intubation stylet OPTIONAL ALS EQUIPMENT (No minimums apply) Formatted: Left Cyanide Antidote Kit

Policy 504: ALS and BLS Unit Equipment and Supplies Page 6 of 5

BLS Unit Search and PSV/CCT FR/ALS Minimum Amount ALS Unit Minimum Rescue Minimum Minimum Amount Minimum Amount Amount Amounts D. MEDICATION, MINIMUM AMOUNT Adenosine, 6 mg 3 3 3 3 Albuterol 2.5mg/3ml 6 2 3 1 Aspirin, 81mg 4 ea 81 mg 4 ea 81 mg 4 ea 81 mg 4 ea 81 mg Amiodarone, 50mg/ml 3ml 6 3 6 3 Atropine sulfate, 1 mg/10 ml 2 2 2 2 Diphenhydramine (Benadryl), 50 mg/ml 2 1 1 2 Calcium chloride, 1000 mg/10 ml 2 1 1 1 Dextrose • 5% 50ml, AND 2 1 2 1 • 10% 250 ml, OR 5 2 2 2 • 50%, 25 GM/50 2 1 2 1 Epinephrine • Epinephrine , 1mg/ml 2 5 5 5 5 • 1 mL ampule / vial, OR 2 4 2 2 2 • Adult auto-injector (0.3 mg), AND 2 4 2 2 2 Peds auto-injector (0.15 mg) • Epinephrine 0.1mg/ml (1 mg/10ml preparation) 6 3 6 4 Fentanyl, 50 mcg/mL 2 2 2 2 Glucagon, 1 mg/ml 2 1 2 1 Lidocaine, 100 mg/5ml 2 2 2 2 Magnesium sulfate, 1 gm per 2 ml 4 4 4 4 5 mg/ml 5 mg/ml 5 mg/ml 5 mg/ml Midazolam Hydrochloride (Versed) 2 vials 2 vials 2 vials 2 vials Morphine sulfate, 10 mg/ml (Only required during a Fentanyl shortage) 2 2 2 2 Naloxone Hydrochloride (Narcan) • IN concentration - 4 mg in 0.1 mL (optional for ALS and non-911 BLS units), OR 2 5 5 5 5 • IM / IV concentration – 2 mg in 2 mL preload (optional for non-911 BLS units) 2 5 5 5 5 Nitroglycerine preparations, 0.4 mg 1 bottle 1 bottle 1 bottle 1 bottle Normal saline, 10 ml 2 2 2 2

Ondansetron (Zofran) • 4 mg IV single use vial 4 4 4 4 • 4 mg oral 4 4 4 4 Sodium Bicarbonate, 1 mEq/mL 2 1 1 1

Tranexamic Acid (TXA) 1 gm/10 mL 2 1 1 1

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number: INTRAOSSEOUS INFUSION 717 APPROVED: Date: September 1, 2017 Administration: Steven L. Carroll, Paramedic APPROVED: Date: September 1, 2017 Medical Director: Daniel Shepherd, MD Origination Date: September 10, 1992 Date Revised: April 13, 2017 Effective Date: September 1, 2017 Date Last Reviewed: April 13, 2017 Review Date: April, 2019

I. PURPOSE: To define the indications, procedure, and documentation for intraosseous insertion (IO) and infusion by paramedics. II. AUTHORITY: Health and Safety Code, Sections 1797.178, 1797.214, 1797.220, 1798 and California Code of Regulations, Title 22, Sections 100145 and 100169. III. POLICY: IO may be performed by paramedics who have successfully completed a training program approved by the EMS Medical Director. A. Training The EMS service provider will ensure their paramedics successfully complete an approved training program and will notify EMS when that is completed. B. Indications Patient with an altered level of consciousness (ALOC) or in extremis AND there is an urgent need to administer intravenous fluids or medications AND venous access is not readily available. 1. Manual IO: For patients less than 8 years of age. 2. EZ-IO device: For patients of all ages. C. Contraindications 1. Recent fracture (within 6 weeks) of selected bone. 2. Congenital deformities of selected bone. 3. Grossly contaminated skin or infection at the insertion site. 4. Excessive adipose tissue at the insertion site with the absence of anatomical landmarks. 5. IO in same bone within previous 48 hours. 6. History of significant orthopedic procedures at insertion site (ex. prosthetic limb or joint). IV. PROCEDURE: A. Manual IO insertion Policy 717: Intraosseous Infusion Page 2 of 6 ______

1. Assemble the needed equipment a. 16-18 gauge IO needle (1.5 inches long) b. Alcohol wipes c. Sterile gauze pads d. Two (2) 5 mL syringes and a primed IV line (with or without stopcock) e. IV fluids: 500 mL NS only f. Tape g. Splinting device 2. Choose the appropriate insertion site. Locate the landmarks approximately 2 cm below the patella and 1 cm medial, on the anteromedial flat bony surface of the proximal tibia. 3. Prepare the site utilizing aseptic technique with alcohol wipe. 4. Fill one syringe with NS 5. To insert the IO needle: a. Stabilize the site. b. Grasp the needle with obturator and insert through skin over the selected site at a 90° angle to the skin surface. c. Once the bone has been reached, continue to apply pressure rotating and gently pushing the needle forward. d. When the needle is felt to 'pop' into the bone marrow space, remove the obturator, attach the empty 5 mL syringe and attempt to aspirate bone marrow. e. For responsive patient infuse 2% cardiac lidocaine prior to fluid/medication administration for pain management: 0.5 mg/kg (max 40 mg) slow IVP over 60 seconds. f. Attach the 5 mL syringe containing NS and attempt to flush the IO needle. If successful, remove the syringe, connect the IV tubing and secure the needle. g. Infuse NS and/or medications. h. Splint and secure the IO needle. i. Document distal pulses and skin color to extremity utilized for IO insertion before and after procedure. Monitor for complications. B. EZ-IO insertion 1. Assemble the needed equipment Policy 717: Intraosseous Infusion Page 3 of 6 ______

a. Choose appropriate size IO needle 1) 15 mm needle sets (pink): 3-39 kg 2) 25 mm needle sets (blue): ≥ 40 kg 3) 45 mm needle sets (yellow): For humerus insertion or patients with excessive adipose tissue at insertion site b. Alcohol wipes c. Sterile gauze pads d. 10 mL syringe e. EZ Connect tubing f. IV fluids 1) 3-39 kg: 500 mL NS 2) ≥40 kg: 1 L NS g. Tape or approved manufacturer securing device 2. Prime EZ Connect tubing with 1 mL fluid a. If unresponsive use normal saline. b. If responsive prime with cardiac lidocaine as instructed below. 3. Locate the appropriate insertion site. The proximal tibia site is preferred. The proximal humerus is an acceptable alternative for adult patients (18 years of older). 4. For a proximal tibia IO the correct insertion site is on the anteromedial flat surface of the proximal tibia. a. Pediatric: 2 cm below the patella, 1 cm medial b. Adult: 2 cm medial to the tibial tuberosity 5. The correct insertion site for the proximal humerus is on the most prominent portion of the greater tubicle, 1-2cm above the surgical neck. 6. Prepare the site utilizing aseptic technique with alcohol wipes. 7. To insert the EZ-IO needle at the proximal tibia: a. Connect appropriate size needle set to the EZ-IO driver. b. Stabilize the site. c. Position the EZ-IO needle at 90° to the underlying bone and insert it into the skin. Continue to insert the needle until contacting the bone. Ensure at least one black band is visible above the skin. d. Once contact with the bone is made, activate the driver and advance the needle with light steady pressure until the bone has been penetrated. Policy 717: Intraosseous Infusion Page 4 of 6 ______

e. Once properly placed, attach primed EZ Connect tubing and attempt to aspirate bone marrow. f. For responsive patients, slow infusion of 2% cardiac lidocaine over 60 seconds prior to fluid/medication administration for pain management. 1) 3-39 kg: 0.5 mg/kg 2) ≥40 kg: 40 mg 3) Adjust for EZ-IO connector tubing g. Flush with 10 mL NS to assess patency. If successful, begin to infuse fluid. h. Splint the IO needle with tape or an approved manufacturer stabilization device. i. Document time of insertion on included arm band and place on patient’s wrist. j. Document distal pulses and skin color before and after procedure and monitor for complications. k. Manual insertion can be attempted in the event of driver failure. 8. To insert the EZ-IO at the proximal humerus: a. Connect the yellow (45mm) needle to the EZ-IO driver. b. Locate and stabilize the site. c. Point the needle set tip at a 45-degree angle to the anterior plane and posteromedial. Insert the needle into the skin until you contact bone. Ensure at least one black band (5mm) is visible above the skin. d. Activate the driver and advance the needle with light, steady pressure until the bone has been penetrated. e. Once properly placed, attach primed EZ Connect tubing and attempt to aspirate bone marrow. f. For responsive patients, slow infusion of 2% cardiac lidocaine over 60 seconds prior to fluid/medication administration for pain management. 1) 3 – 39 kg: 0.5 mg/kg 2) ≥40 kg: 40 mg 3) Adjust for EZ-IO connector tubing Policy 717: Intraosseous Infusion Page 5 of 6 ______

g. Flush with 10 ml NS to assess patency. If successful, begin to infuse fluid. h. Splint the IO needle with tape or an approved manufacturer stabilization device. Maintain adduction of the arm and avoid extension of the shoulder. i. Document time of insertion on included arm band and place on patient’s wrist. j. Document distal pulses and skin color before and after procedure and monitor for complications. C. IO Fluid Administration 1. Active pushing of fluids may be more successful than gravity infusion. Use of a pressure to assist with fluid administration is recommended, and usually needed, but not required. 2. Fluid administration on smaller patients should be given via syringe boluses to control/monitor amount infused. Close observation of the flow rate and total amount of fluid infused is required. 3. If infiltration occurs or the IO needle is accidentally removed, stop the infusion, leave the connector tubing attached. D. Documentation 1. Document any attempt(s) at establishing a peripheral IV prior to attempting/placing an IO infusion in the Ventura County Electronic Patient Care Report (VCePCR) system. 2. The site and number of attempts, success, complications, and any applicable comments related to attempting an IO infusion shall be documented on the VCePCR. Any medications administered shall also be documented in the appropriate manner on the VCePCR. E. Quality Assurance Each use of an IO infusion will be reviewed by EMS. Data related to IO attempts will be collected and analyzed directly from the VCePCR system. Policy 717: Intraosseous Infusion Page 6 of 6 ______

Appendix B

VENTURA COUNTY EMERGENCY MEDICAL SERVICES AGENCY

Skills Assessment

Name______Agency______Date______

Demonstrates, proper body substance isolation

States indication for EZ-IO use

States contraindication for EZ-IO use

Correctly locates target site

Cleans site according to protocol

Considers 2% cardiac lidocaine for patients responsive to pain

Correctly assembles EZ-IO Driver and Needle Set

Stabilizes the insertion site, inserts EZ-IO Needle Set, removes stylet and confirms placement

Demonstrates safe stylet disposal

Connects primed extension set and flushes the catheter

Connects appropriate fluid with pressure infuser and adjusts flow as instructed

Demonstrates appropriate securing of the EZ-IO

States requirements for VC EMS documentation

Instructor Signature: ______Date______COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number Out of County Paramedic Internship Approval Process 335 APPROVED: Date: December 1, 2017 Administrator: Steven L. Carroll, EMT-P APPROVED: Date: December 1, 2017 Medical Director: Daniel Shepherd, M.D. Origination Date: October 13, 2005

Date Revised: April 19, 2013 Effective Date: December 1, 2017 Date Last Reviewed: October 12, 2017

Next Review Date: October 31, 2020

I. PURPOSE: To establish a mechanism for notifying the EMS Agency of out of county paramedic student placement within the local EMS system and ensure appropriate medical control and oversight of Paramedic Interns prior to practicing within the local jurisdiction. II. AUTHORITY: Health and Safety Code Sections 1797.107, 1797.172, 1797.173, 1798, and California Code of Regulation, Title 22, Sections 100147 and 100153. III. DEFINITIONS: This policy defines the standards for field interns, whose paramedic training program is located outside the jurisdiction of the paramedic training program approving authority, and who wish to complete all or a portion of their field internship requirements with an advanced life support provider in Ventura County. A paramedic intern is a person trained by a VCEMS approved training program who while under the supervision of an approved preceptor may provide ALS care as directed by local EMS medical control. The intern shall be supervised, trained, counseled and evaluated by the designated preceptor and his/her affiliated training program. IV. POLICY: The following requirements must be completed prior to internship commencement. A. Paramedic Training Program Responsibilities: 1. Letter requesting approval for out of county paramedic student placement within the local EMS system 2. Copy of Paramedic Training Program’s CAAHEP accreditation. 3. Evidence of a contract to provide field training between the ALS training program and the ALS provider agency where the intern will be training. 4. Copies of forms used to document student’s progress, continuum of care and the training program’s collaboration with the field preceptor. Policy 335: Out of County Paramedic Internship Approval Process Page 2 of 4 ______

5. Confirmation that the intern successfully completed didactic and clinical training at the same institution that is requesting internship placement. This requirement may be reduced at the discretion of the VCEMS Medical Director. B. Paramedic Intern Responsibilities: 1. Completed VCEMS application 2. Copy of intern’s valid government issued photo identification. 3. Copy of intern’s professional rescuer level CPR card. 4. Completion of a California Department of Justice (CA DOJ Live Scan) background check through VCEMS. A copy of the Request for Live Scan Services form must be submitted to VCEMS at time of application. 5. Letter from training program confirming intern’s good standing and current affiliation with a VCEMS approved training program including dates of hospital clinical completion and contact name and phone number for the instructor responsible for the intern. 6. Letter from training program confirming that the intern has performed five (5) successful live patient endotracheal intubations during primary ALS training. 7. Upon completion of above requirements, intern shall contact VCEMS to schedule appointment to complete internship process. C. ALS Provider Responsibilities: 1 Notify VCEMS of intention to provide field internship for a specific intern. 2. Provider agency shall submit a completed Appendix A to VCEMS for each intern who is placed for internship prior to the start date. 3. Ensure that the student has been oriented to the Ventura County EMS System including local policies, procedures and treatment protocols. D. Paramedic Intern Photo Identification: 1. Upon VCEMS verification of all above requirements including background check results, intern will be issued a Paramedic Intern photo identification badge that must be worn visible at all times while providing pre-hospital care in Ventura County. Internship shall not start until the Paramedic Intern photo identification badge is issued. Policy 335: Out of County Paramedic Internship Approval Process Page 3 of 4 ______

E. In order to ensure an adequate number of internship placements for in county paramedic students, no internships involving out of county students will be permitted from February 1st through May 31st of each year. Placement for internships for out of county interns must be initiated prior to November 1st in order to allow adequate time for completion before January 31st.

Policy 335: Out of County Paramedic Internship Approval Process Page 4 of 4 ______

ATTACHMENT A Out of County Paramedic Internship Authorization (To be completed by ALS provider agency and submitted to VCEMS)

Intern Name Start date of internship Agency sponsoring intern Preceptor name Training Institute

Information below is to be completed by the EMS Agency

Authorization approved: Date Authorization is not approved because: ALS Provider notified on: Date Training Program notified on: Date EMS Representative Signature

AVCDS LOGIN LOGIN PASSWORD

The password issued is a default password. You must change it upon successful login. COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number Notification Of Personnel Changes-Provider 342 APPROVED: Date: June 1, 2017 Administration: Steven L. Carroll, EMT-P APPROVED: Date: June 1, 2017 Medical Director: Daniel Shepherd, MD Origination Date: May 15, 1987 Date Revised: May 11, 2017 Effective Date: June 1, 2017 Last Review: May 11, 2017 Review Date: May 2020

I. PURPOSE To define a procedure to assure that the Ventura County Emergency Services Agency is notified of hiring or termination of employment of an EMT or paramedic and MICN. II. AUTHORITY: Health and Safety Code, Chapter 1, Article 1. III. POLICY Each provider of prehospital EMS services shall notify, Emergency Medical Services Administrative Office, in writing or by e-mail, of hiring or termination of employment of an EMT, paramedic or MICN within 5 days of taking action.

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number: MEDICAL CONTROL AT THE SCENE: EMS PREHOSPITAL PERSONNEL 601

APPROVED: Date: December 1, 2017 Administration: Steven L. Carroll, EMT-P

APPROVED: Date: December 1, 2017 Medical Director Daniel Shepherd, MD Origination Date: October 1, 1993 Date Revised: September 14, 2017 Effective Date: December 1, 2017 Date Last Reviewed: September 14, 2017 Review Date: September, 2020

I. PURPOSE: To establish guidelines for medical control at the scene of a medical emergency. II. AUTHORITY: California Health and Safety Code, Sections 1797.220, and 1798.6 II. POLICY: Authority for patient health care management in an emergency shall be vested in that licensed and/or certified health care professional, which may include any paramedic or other prehospital emergency medical personnel, at the scene of an emergency who is most medically qualified specific to the provision of rendering emergency medical care. If no licensed or certified health care professional is available, the authority shall be vested in the most appropriate medically qualified representative of public safety agencies who may have responded to the scene of the emergency. (Health and Safety Code, Section 1796(a)) III. PROCEDURE: The following shall be utilized to determine authority for medical control on scene: A. Prehospital care personnel, certified and/or accredited in Ventura County, have authority for health care management in the following ascending order: 1. EMT 3. EMT-ALS Assist 4. Paramedic, operating in accordance with established Ventura County EMS Agency policies and procedures, under medical control from a BH, or who is providing care under the direct order of a physician on scene. a. This does not allow the paramedic to receive orders from medical personnel at the scene who are not MD's or DO's. This order is determined by training hours, scope of practice, and available supplies and equipment.

Policy 601: Medical Control at the Scene: EMS Prehospital Personnel Page 2 of 2

6. The first paramedic on scene assumes initial medical control of the patient. Medical Control of the patient and the best course of patient care will be determined by paramedics on scene, in conjunction with the base hospital MICN/base physician (when indicated). In all cases, transfer of medical control and/or patient care will be done in a coordinated fashion.

COUNTY OF VENTURA EMERGENCY MEDICAL SERVICES HEALTH CARE AGENCY POLICIES AND PROCEDURES Policy Title: Policy Number: Hospice Patient Care 629

APPROVED: Date: December 1, 2019 Administration: Steven L. Carroll, Paramedic

APPROVED: Date: December 1, 2019 Medical Director: Daniel Shepherd, M.D. Origination Date: 10/10/2019 Date Revised: Effective Date: December 1, 2019 Date Last Reviewed: Next Review Date: 10/31/2020

I. PURPOSE: To define the management of patients enrolled in hospice.

II. AUTHORITY: California Health and Safety Code, §1798, §1798.2; §1798.160 and §1798.170; California Code of Regulations, Title 22, §100145 and §100146 . III. POLICY: A. EMS personnel shall evaluate and treat patients enrolled in hospice programs with the goal of enabling them to remain at home and continue their desired treatment plan according to the following procedures. IV. PROCEDURE: A. Patient Management: 1. The responding EMS personnel will evaluate the presenting complaint, confirm that the patient is on hospice and identify the current hospice provider. 2. A phone call shall be established between EMS and the on call hospice provider to communicate on scene findings. 3. EMS and Hospice communication will be centered around the following goals; a. Identifying a need for the hospice provider to respond to the scene b. Identifying EMS interventions or actions which may facilitate patient comfort and prevent transport. c. Identifying hospice resources or interventions which may facilitate patient comfort and prevent transport. Policy 629: Hospice Patient Care Page 2 of 2

d. Identifying the unique cases where transport is necessary for hospital treatment or diagnostics which are required in order to best continue in home treatment. In such cases the hospice provider should be able to confirm that hospice enrollment will not be cancelled as a result of transport to ED.

B. Resources / response: 1. Most often transport can be avoided and comfort optimized utilizing only the initial paramedic response along with follow up from the hospice agency. 2. EMS providers should consult with or request a response from one of the following: a. Online medical direction from base hospital physician b. Community paramedic response c. EMS supervisor response Ventura County EMS County Wide Protocols Policy 705.16

Neonatal Resuscitation BLS Procedures Newly Born Infant Infant up to 48 hours old Provide warmth, dry briskly and discard wet linen Provide warmth • Suction ONLY if secretions, including • Suction ONLY if secretions cause airway meconium, cause airway obstruction obstruction Assess while drying infant • Stimulate briefly (<15 seconds) 1. Full term? ◦ Flick soles of infant’s feet 2. Crying or breathing? ◦ Rub infant’s back with towel 3. Good muscle tone? Provide warm/dry covering If “YES” to all three Continue to assess • Place skin-to-skin with mother • Cover both with dry linen • Observe breathing, activity, color If “NO” to any of three • Stimulate briefly (<15 seconds) ◦ Flick soles of infant’s feet ◦ Briskly rub infant’s back • Provide warm/dry covering • Continue to assess Assess Breathing • If crying or breathing, assess circulation • If apneic or gasping ◦ Positive pressure ventilations (PPV) with BVM and ROOM AIR at 40-60 breaths per minute for 30 seconds . Continue PPV, reassessing every 30 seconds, until infant is breathing adequately ◦ Reassess breathing, assess circulation Assess Circulation • If HR between 60 and 100 bpm ◦ PPV with BVM and ROOM AIR at 40-60 breaths per minute for 30 seconds . Continue PPV, reassessing every 30 seconds, until infant maintains HR >100 bpm • If HR < 60 bpm ◦ CPR at 3:1 ratio for 30 seconds . 90/min compressions . 30/min ventilations . Continue CPR, reassessing every 60 seconds, until HR > 60 bpm ◦ If no improvement after 90 seconds of ROOM AIR CPR, add supplemental O2 until HR > 100 ALS Prior to Base Hospital Contact Establish IO line only in presence of CPR Asystole OR Persistent Bradycardia < 60 bpm PEA • Epinephrine 0.1mg/mL • Epinephrine 0.1mg/mL o IO – 0.01mg/kg (0.1mL/kg) q 3-5 min o IO – 0.01mg/kg (0.1mL/kg) q 3-5 min • Normal Saline • Normal Saline o IO bolus – 10mL/kg o IO bolus – 10mL/kg Base Hospital Orders only Consult with ED Physician for further treatment measures Additional Information: • Resuscitation efforts may be withheld for extremely preterm infants (< 21 weeks or < 9 inches long). Sensitivity to the desires of the parent(s) may be considered. If uncertain as to gestational age, begin resuscitation. • A rising heart rate is the best indicator of adequate PPV

Effective Date: December 1, 2018 Date Revised: August 9, 2018 Next Review Date: August 31, 2020 Last Reviewed: August 9, 2018

VCEMS Medical Director